How to Diagnose and Document Sleep Apnea Using ICD-10 Codes

How to Diagnose & Document Sleep Apnea Using ICD-10 Codes

Sleep apnea can occur when the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow. The article details the documentation guidelines for this condition using the correct ICD-10 codes.

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Sleep apnea is a common and serious sleep disorder in which an individual’s breathing repeatedly stops and starts during sleep. People with this condition snore loudly and will feel tired even after a full night's sleep. A person suffering from this condition will unknowingly stop breathing repeatedly throughout their sleep. The involuntary pause in breathing can result either from a blocked airway or a signaling problem in the brain. Once the airway is opened or the breathing signal is received, the person may snort or awaken completely with a sensation of gasping, smothering, or choking. The condition can be caused by one’s physical structure or other medical conditions such as – obesity, large tonsils, premature birth, heart or kidney failure, endocrine disorders, neuromuscular disorders and other genetic syndromes. There are different types of sleep apnea and the main types include - obstructive sleep apnea, central sleep apnea and complex sleep apnea. Reports suggest that approximately 18 million Americans suffer from this condition, but only 20 percent have been diagnosed and treated.

Untreated sleep apnea can lead to several serious health complications such as heart disease and depression. It can leave a person feeling drowsy thereby increasing the risk of accidents while driving or working. Treatment for this condition mainly depends on the specific causes and the level and type of apnea. The main goal of treatment is to normalize breathing during sleep. As the coding and documentation for sleep apnea is nuanced and complex, most physician practices rely on medical coding outsourcing to meet their medical billing and coding requirements.

Signs and Symptoms In most cases, patients suffering from sleep apnea may be unaware about their symptoms. The signs and symptoms would depend on the type of sleep apnea a person is suffering from. Common signs and symptoms include  Loud snoring (usually more prominent in obstructive sleep apnea)

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 Episodes of breathing cessation during sleep (witnessed by another person)  Restless sleep or insomnia  Morning headache  Irritability  Heartburn  Excessive daytime sleepiness and fatigue (hypersomnia)  Decreased libido and erectile dysfunction  Awakening with a dry mouth or sore throat  Attention problems  Abrupt awakenings accompanied by shortness of breath

How to Accurately Diagnose and Document Sleep Apnea Initial diagnosis and evaluation of this sleep disorder will be based on the individual signs and symptoms displayed by the patient. Sleep specialists will ask questions about the sleep environment which would include typical sleep schedule, breathing pattern and other body functions during sleep. They may conduct different tests such as nocturnal polysomnography and home sleep tests to detect the pattern of sleep apnea.

Mild cases of sleep apnea can be effectively managed by incorporating healthy/positive lifestyle changes such as reducing body weight or quitting the habit of smoking. For those who have nasal allergies, physicians may recommend medications for the same. In some cases, if any of the above measures don't improve the signs and symptoms, certain devices such as Continuous Positive Airway Pressure (CPAP), oral appliances, Expiratory Positive Airway Pressure (EPAP) and other airway pressure devices can help open up a blocked airway. Surgery may be considered only as a last resort after all the other treatments have failed.

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ICD-10 Codes to Use Allergy and sleep medicine medical coding involves the use of specific ICD-10 codes to document any such conditions, including sleep apnea.

Sleep medicine physicians who treat this condition rely on reputable medical billing companies to code the condition accurately. ICD-10-CM codes used to indicate a diagnosis of sleep apnea for reimbursement purposes include –  G47.3 - Sleep apnea  G47.30 - Sleep apnea, unspecified  G47.31 - Primary central sleep apnea  G47.32 - High altitude periodic breathing  G47.33 - Obstructive sleep apnea (adult) (pediatric)  G47.34 - Idiopathic sleep related non-obstructive alveolar hypoventilation  G47.35 - Congenital central alveolar hypoventilation syndrome  G47.36 - Sleep related hypoventilation in conditions classified elsewhere  G47.37 - Central sleep apnea in conditions classified elsewhere  G47.39 - Other sleep apnea

There are several risk factors associated with sleep apnea which may include unhealthy lifestyle habits, age, sex, family history and genetics. Healthy lifestyle changes can reduce your risk for developing sleep apnea. In most cases, self-care is the most appropriate way to deal or manage the condition of sleep apnea. Incorporating self-care strategies such as quitting the habit of smoking, reducing excessive body weight, regular physical exercise, sleeping on your side or abdomen rather than on your back, avoiding the intake of alcohol and certain medications such as tranquilizers and sleeping pills and keeping the nasal passages open at night can help better control this disorder.

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